[SPECIAL SENSES] POST TEST

a. Call the physician.

impending glaucoma

During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action?

a. Call the physician.

b. Reassure the client that this is normal.

c. Turn the client onto his or her operative side.

d. Administer the prescribed pain medication and antiemetic

c. Eye medications will need to be administered for life.

all are correct but miotic eyedrops are the priority

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care?

a. Avoid overuse of the eyes.

b. Decrease the amount of salt in the diet.

c. Eye medications will need to be administered for life.

d. Decrease fluid intake to control the intraocular pressure.

d. A sense of a curtain falling across the field of vision

b. retinal detachment is painless

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye disorder?

a. Total loss of vision

b. Pain in the affected eye

c. A yellow discoloration of the sclera

d. A sense of a curtain falling across the field of vision

b. Tinnitus

tinnitus first before hearing loss

A client is diagnosed with a disorder involving the inner ear. Which is the most common client complaint associated with a disorder involving this part of the ear?

a. Pruritus

b. Tinnitus

c. Hearing loss

d. Burning in the ear

d. Blurred vision

a. diplopia - late

b. painless

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation?

a. Diplopia

b. Eye pain

c. Floating spots

d. Blurred vision

b. Avoid sudden head movements.

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo?

a. Increase sodium in the diet.

b. Avoid sudden head movements.

c. Lie still and watch the television.

d. Increase fluid intake to 3000 mL a day.

b. Instruct the client that he or she may need glasses when driving.

pt is near-sighted

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding?

a. Provide the client with materials on legal blindness.

b. Instruct the client that he or she may need glasses when driving.

c. Inform the client of where he or she can purchase a white cane with a red tip.

d. Inform the client that it is best to sit near the back of the room when attending lectures.

a. "It is important that I have surgery done as soon as possible to prevent permanent damage to my vision."

pharma management before surgery

A nurse speaks with a client who recently learned he has beginning cataracts in both eyes. Which statement made by the client should a nurse correct?

a. "It is important that I have surgery done as soon as possible to prevent permanent damage to my vision."

b. "Cataracts are corrected by surgery, with each eye done at different times."

c. "The surgical treatment of a cataract involves the removal of the client's own lens from the eye."

d. "An intraocular lens is placed in the eye at the time of surgery.

b. Cough and deep breathe every 2 hours.

increased pressure

A nurse is discharging a client who underwent outpatient cataract surgery. Which intervention should NOT be included in the discharge instructions to the client and family member?

a. Wear eye shield at night.

b. Cough and deep breathe every 2 hours.

c. Rest in the bed while the head of the elevated at 30 degrees.

d. Avoid getting water in the client's eye when washing client's hair.

d. Notify doctor and have the client transported promptly to a facility for ophthalmologic referral and treatment.

A nurse working in a long-term care facility suspects a client is experiencing detachment of the retina. A nurse should:

a. Patch both eyes and place the client in a prone position.

b. Flush the eye thoroughly with saline solution and apply a pressure bandage.

c. Apply an eye shield to the affected eye and administer the prescribed oral analgesic medication.

d. Notify doctor and have the client transported promptly to a facility for ophthalmologic referral and treatment.

d. Normal intraocular pressure

A client is seen in an emergency department and is diagnosed with closed-angle glaucoma. In a review of the client's medical record, which documented finding should the nurse question?

a. Eye pain

b. Nausea and vomiting

c. Sudden onset of symptoms

d. Normal intraocular pressure

c. remain under the care of and have regular eye examinations by an eye specialist physician.

d. not PRN

A nurse, teaching a client with open-angle glaucoma, should instruct the client to:

a. include foods high in omega 3 fatty acids in the diet.

b. restrict oral intake to lessen the need for glaucoma medications.

c. remain under the care of and have regular eye examinations by an eye specialist physician.

d. administer prescribed eye drop medication when feeling pressure within the eyes.

c. growth of abnormal blood vessels in the macula.

A client tells a nurse that he has been diagnosed with macular degeneration, "wet type." Based on the nurse's knowledge of this diagnosis, the nurse, examining this client's eyes using an ophthalmoscope, should expect to observe:

a. clouding of the lens of the eye.

b. atrophy of structures in the macula.

c. growth of abnormal blood vessels in the macula.

d. a thin, grayish-white area on the edge of the cornea.

b. Visual distortions in the central vision

a. retinal detachment

c. open angle glaucoma

d. cataract

A client diagnosed with macular degeneration is told the condition is progressing to an advanced stage. When completing the client's health assessment, which findings should the nurse expect the client to report?

a. Curtain appearance over part of the visual field

b. Visual distortions in the central vision

c. Loss of peripheral vision

d. Clouding of the lens

d. Wide brimmed hat

photosensitivity

A client with macular degeneration is scheduled for photodynamic therapy with the use of verteporfin. Which of the following items should the client bring before procedure?

a. Moisturizer

b. Reading glass

c. Cotton underwear

d. Wide brimmed hat

b. Note the time of day the test was done

IOP in morning before reporting

d. semi-fowler's

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23. What would be the nurse's initial action?

a. Apply normal saline drops

b. Note the time of day the test was done

c. Contact the primary health care provider (PHCP)

d. Instruct the client to sleep with the head of the bed flat

c. Speak at normal tone and pitch, slowly and clearly

presbycusis = age-related hearing loss

other choices are loudly

The nurse notes that the primary health care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information what action would the nurse take?

a. Speak loudly but mumble or slur the words

b. Speak loudly and clearly while facing the client

c. Speak at normal tone and pitch, slowly and clearly

d. Speak loudly and directly into the client's affected ear

a. The right eye is tested, followed by the left eye, and then both eyes are tested

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test?

a. The right eye is tested, followed by the left eye, and then both eyes are tested

b. Both eyes are assessed together, followed by an assessment of the right eye and then the left eye.

c. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the largest line on the chart.

d. The client is asked to stand at a distance of 40 feet (12 meters) from the chart and to read the line that can be read 200 feet (60 meters) away by an individual with unimpaired vision.

b. Perform visual acuity tests.

acd causes more damage

wood cannot be diluted by flushing

The client arrives in the emergency department with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eyes and notes a piece of wood protruding from the eye. What is the initial nursing action?

a. Apply an eye patch

b. Perform visual acuity tests.

c. Irrigate the eye with sterile saline

d. Remove the piece of wood using a sterile clamp

c. Speak at a normal volume

The nurse is caring for a hearing-impaired client. Which approach will facilitate communication?

a. Speak loudly

b. Speak frequently

c. Speak at a normal volume

d. Speak directly into the impaired ear